Provider Demographics
NPI:1255589784
Name:AVERELL, JOHN CHARLES (IDC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHARLES
Last Name:AVERELL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 FOOLS GOLD WAY #2
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913
Mailing Address - Country:US
Mailing Address - Phone:619-532-5110
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER SAN DIEGO
Practice Address - Street 2:BLDG 14
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:92134
Practice Address - Country:US
Practice Address - Phone:619-532-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman